REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI )S.S

AFFIDAVIT OF CAR INCIDENT

I, MARIA THERESA C. ROMERO, of legal age, Filipino, widow and with
residence address at 24 Mauban St., Brgy. 127, Caloocan City, After having been
duly sworn to in accordance with law, do hereby depose and state:

That I am the registered owner of a motor vehicle more particularly described

as follows:
MAKE/TYPE : SUBARU/WAGON PLATE NO. : NAA 6088
YEAR MODEL : 2018 CR NO. : 301392615
ENGINE NO. : YB15942
CHASSIS NO. :

That on July 8 2021 around 3:00 in the afternoon, I parked the aforementioned
vehicle at SM City San Lazaro Manila Parking Area. Upon returning to my vehicle, I
noticed that the right side tail/brake light is broken in which appears to be a hit and
run by an anonymous vehicle;

That the aforementioned situations was an incident beyond my control after

exercising extraordinary care and diligence to safety;

That I am executing this affidavit to attest to the truth of the foregoing facts
and for the purpose of an Insurance Claim in hands of People’s General Insurance
Corporation at 420 Calle Magallanes, Intramuros, Manila

IN WITNESS WHEREOF, I have hereunto affixed my signature this 14 th day

of July 2021 at the City of Makati.

MARIA THERESA C. ROMERO

Affiant

Subscribed and sworn to before me this 14 th day of July 2021 at the City of
Makati, and affiant exhibiting to me her Driver’s License ID No. N11-84-033433.

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